Trends in Mortality and Costs of Pediatric Extracorporeal Life Support

Cardiovascular Disease in Pregnancy: Clinical Outcomes and Cost-Associated Burdens From a National Cohort at Delivery

Background

Cardiovascular disease (CVD) in pregnancy is a leading cause of maternal morbidity and mortality in the United States, with an increasing prevalence.

Objectives

This study aimed to examine risk factors for adverse maternal cardiac, maternal obstetric, and neonatal outcomes as well as costs for pregnant people with CVD at delivery.

Methods

Using the National Inpatient Sample 2010-2019 and the Internal Classification of Diseases diagnosis codes, all pregnant people admitted for their delivery hospitalization were included. CVD diagnoses included congenital heart disease, cardiomyopathy, ischemic heart disease, arrhythmias, and valvular disease. Multivariable regressions were used to analyze major adverse cardiovascular events (MACE), maternal and fetal complications, length of stay, and resource utilization.

Results

Of the 33,639,831 birth hospitalizations included, 132,532 (0.39%) had CVD. These patients experienced more frequent MACE (8.5% vs 0.4%, P < 0.001), obstetric (24.1% vs 16.6%, P < 0.001), and neonatal complications (16.1% vs 9.5%, P < 0.001), and maternal mortality (0.16% vs 0.01%, P < 0.001). Factors associated with MACE included cardiomyopathy (adjusted OR [aOR]: 49.9, 95% CI: 45.2-55.1), congenital heart disease (aOR: 13.8, 95% CI: 12.0-15.9), Black race (aOR: 1.04, 95% CI: 1.00-1.08), low income (aOR: 1.06, 95% CI: 1.02-1.11), and governmental insurance (aOR: 1.03, 95% CI: 1.00-1.07). On adjusted analysis, CVD was associated with higher odds of maternal mortality (aOR: 9.28, 95% CI: 6.35-13.56), stillbirth (aOR: 1.66, 95% CI: 1.49-1.85), preterm birth (aOR: 1.33, 1.27-1.39), and congenital anomalies (aOR: 1.84, 95% CI: 1.69-1.99). CVD was also associated with an increase of $2,598 (95% CI: $2,419-2,777) per patient during admission for delivery.

Conclusions

CVD in pregnancy is associated with higher rates of adverse outcomes. Our study highlights the association of key clinical and demographic factors with CVD during pregnancy to emphasize those at highest risk for complications.

Assessment of echocardiographic interpretation of dual-lumen cannula during venovenous extracorporeal membrane oxygenation use for pediatric respiratory failure

PURPOSE

Echocardiography is considered essential during cannulation placement and manipulations. Literature evaluating transthoracic echocardiography (TTE) usage during pediatric VV-ECMO is scant. The purpose of this study is to describe the use of echocardiography during VV-ECMO at a large, quaternary children's hospital.

METHODS

A retrospective, single-year cohort study was performed of pediatric patients on VV-ECMO via dual-lumen cannula at our institution from January 2019 through December 2019. For each echocardiogram, final cannula component (re-infusion port (ReP), distal tip, proximal port and distal port) positions were evaluated by one echocardiographer. For TTEs with ReP in the right atrium, two echocardiographers independently evaluated ReP direction using 2-point (Yes/No) and 4-point scales, which were semi-quantitative protocols using color Doppler images to estimate ReP jet direction to the tricuspid valve. Cohen's kappa or weighted kappa was used to measure interrater agreement.

RESULTS

During study period, 11 patients (64% male) received VV-ECMO with 49 TTEs and one transesophageal echocardiogram performed. The median patient age was 4.3 years [IQR: 1.1-11.5] and median VV-ECMO run time of 192 h [90-349]. The median time between TTEs on VV-ECMO was 34 h [8.3-65]. Most common position for the ReP was the right atrium (n = 33, 67%), and ReP location was not identified in five TTEs (10%). For ReP flow direction, echocardiographers agreed on 82% of TTEs using 2-point evaluation. There was only moderate agreement between echocardiographers on the 2-point and 4-point assessments (k = .54, kw = .46 respectively).

CONCLUSIONS

TTE is the predominant cardiac ultrasound modality used during VV-ECMO for pediatric respiratory failure. Subjective evaluation of VV-ECMO ReP jet direction in the right atrium is challenging, regardless of assessment method.

Two months outcomes following delirium in the pediatric intensive care unit

The lasting consequences of delirium in children are not well characterized. This study aimed to compare the two-month outcomes in pediatric intensive care unit (PICU) survivors according to the presence of delirium. Post-hoc analysis of a single-center prospective study of mechanically ventilated (invasive ventilation or non-invasive ventilation) children followed at the CHU Sainte-Justine PICU follow-up clinic two months after PICU discharge, between October 2018 and August 2022. Delirium was defined as one or more Cornell Assessment of Pediatric Delirium (CAPD) scores ≥ 9. Primary outcome was survivors' quality of life and secondary outcomes were sleep and posttraumatic stress and anxiety and depression in parents. Multivariable linear and logistic regression models assessed the independent associations between delirium and outcomes while adjusting for age, sex, comorbidity, diagnosis, severity of illness, PICU length of stay, and invasive mechanical ventilation. Of the 179 children included over a 47 month-period, 117 (65.4%) had delirium. Children with delirium were more commonly intubated (91.5% vs. 30.7%, p < 0.001) and had higher PELOD-2 scores (10 vs. 4, p < 0.001). On multivariable analysis, delirium was associated with a decreased quality of life at 2.3 months post discharge (p = 0.03). The severity of the delirium episode (higher scores of CAPD) was associated with a higher likelihood of sleep disturbances (OR 1.13, p = 0.01) and parental anxiety (OR 1.16, p = 0.01), in addition to lower quality of life (p = 0.03).Conclusions: Two months following their PICU stay, children with delirium had a lower quality of life, suggesting a lasting effect of delirium on children and their families.

Characteristics, outcomes, and 30-day readmissions following pediatric extracorporeal membrane oxygenation in the United States: A Nationwide Readmissions Database study

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is an increasingly used mode of critical care support for pediatric patients refractory to conventional therapy. We evaluated the characteristics, outcomes, and readmissions rates for pediatric ECMO in the United States.

METHODS

Data was extracted from the Nationwide Readmissions Database, a database designed to support national readmissions analyses, for patients aged 1-18 years undergoing ECMO between 2012-2018. Baseline demographics, comorbidities, and characteristics were identified using International Classification of Diseases codes.

RESULTS

Out of 897,117 index pediatric hospitalizations, 3706 patients underwent ECMO [median age 9 years (IQR 2,15); 51.6% males]. 2246 (60.6%) patients survived to hospital discharge, with a 30-day readmissions rate of 17% among survivors. Cardiac conditions associated with ECMO were congenital heart disease (25.3%), cardiogenic shock (23.6%), and congestive heart failure (16.2%). The common respiratory associations were sepsis (36.2%), pneumonia (35.6%), and asthma (15.4%). Patients who survived were more likely to have diagnoses of asthma, bronchiolitis, myocarditis, pneumonia, and sepsis. Acute kidney injury (51.5%), disseminated intravascular coagulation (22.5%), and surgical site bleeding (12.7%) were the commonly associated complications. The trend for yearly survival rates was not statistically significant (linear p-trend = 0.38).

CONCLUSIONS

Pediatric ECMO continues to be associated with notable mortality and complication rates. We did not observe a meaningful trend for the yearly survival rates over the study period, and over one-sixth of survivors were readmitted within 30-days. More research is needed to identify patients at high risk of mortality and readmissions, to help target resources more efficiently and improve survival.

Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes

BACKGROUND

Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes.

METHODS

This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS).

RESULTS

540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis.

CONCLUSIONS

We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.

Quality improvement strategies in pediatric ECMO

Pediatric extracorporeal membrane oxygenation is an increasingly utilized, life-saving technology with high mortality and morbidity. A complex technology employed urgently or emergently for some of the sickest children in the hospital by a large multidisciplinary team, ECMO is an ideal area for using quality improvement strategies to reduce the variability in care and improve patient outcomes. We review critical concepts from quality improvement and apply them to patient selection and management, staffing, credentialing and continuing education, and the variability of management among providers and institutions.

Hospital ECMO capability is associated with survival in pediatric cardiac arrest

AIM

Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital's ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital.

METHODS

We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0-18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016 and 2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival.

RESULTS

We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p < 0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support.

CONCLUSION

A hospital's ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.

Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature

OBJECTIVES

To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes.

DATA SOURCES

PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population).

STUDY SELECTION

Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support.

DATA EXTRACTION

Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool.

DATA SYNTHESIS

Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors.

CONCLUSIONS

Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.

Anti-Xa testing for pediatric and neonatal patients on extracorporeal membrane oxygenation

INTRODUCTION

To determine if anti-Xa testing is associated with improved outcomes for patients <19-years-old on ECMO.

METHODS

We evaluated the clinical benefit of anti-Xa heparin monitoring utilizing the Bleeding and Thrombosis during ECMO (BATE) database of 514 patients <19-years-old. The BATE database includes incidences of bleeding, thrombosis, and mortality. The database also describes anti-coagulation test utilization. We grouped and analyzed patients based on ECMO indication (cardiac, respiratory, or extracorporeal cardiopulmonary resuscitation [E-CPR]) and age (neonatal vs pediatric). We constructed multivariable logistic regression models to analyze the impact of anti-Xa testing on mortality, bleeding, and thrombosis in each group.

RESULTS

Across the entire population, anti-Xa testing did not have a significant effect on the incidence of mortality (43% with anti-Xa testing vs 49% without), bleeding (68% vs 74%), or thrombosis (37% vs 39%). However, among cardiac indicated patients on ECMO (n = 207), anti-Xa testing was significantly associated with reduced odds ratio (OR) of mortality (adjusted OR 0.527, p = .040) and bleeding (adjusted OR 0.369, p = .021). In addition, among neonatal patients on ECMO (n = 264), anti-Xa testing was associated with a significant reduction in the odds ratio of bleeding (adjusted OR 0.534, p = .046).

CONCLUSION

Anti-Xa testing is associated with improved outcomes among cardiac indicated and neonatal patients on ECMO. Additional research to find the optimal heparin monitoring regimen is needed to better support these critically ill patients. In the interim, we recommend clinicians consider utilizing anti-Xa assays as part of their heparin monitoring plan for neonatal and cardiac indicated patients on ECMO.

Insurance-Based Disparities in Congenital Cardiac Operations in the Era of the Affordable Care Act

A body of literature has previously highlighted the impact of health insurance on observed disparities in congenital cardiac operations. With aims of improving access to healthcare for all patients, the Affordable Care Act (ACA) expanded Medicaid coverage to nearly all eligible children in 2010. Therefore, the present population-based study aimed to examine the association of Medicaid coverage with clinical and financial outcomes in the era the ACA. Records for pediatric patients (≤ 18 years) who underwent congenital cardiac operations were abstracted from the 2010-2018 Nationwide Readmissions Database. Operations were stratified using the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Category. Multivariable regression models were developed to evaluate the association of insurance status on index mortality, 30-day readmissions, care fragmentation, and cumulative costs. Of an estimated 132,745 hospitalizations for congenital cardiac surgery from 2010 to 2018, 74,925 (56.4%) were insured by Medicaid. The proportion of Medicaid patients increased from 57.6 to 60.8% during the study period. On adjusted analysis, patients with Medicaid insurance were at an increased odds of mortality (1.35, 95%CI: 1.13-1.60) and 30-day unplanned readmission (1.12, 95%CI: 1.01-1.25), experienced longer lengths of stay (+ 6.5 days, 95%CI 3.7-9.3), and exhibited higher cumulative hospitalization costs (+ $21,600, 95%CI: $11,500-31,700). The total hospitalization cost-burden for patients with Medicaid and private insurance were $12.6 billion and $8.06 billion, respectively. Medicaid patients exhibited increased mortality, readmissions, care fragmentation, and costs compared to those with private insurance. Our results of outcome variation by insurance status indicate the necessity of policy changes to attempt to approach equality in surgical out comes for this high-risk cohort. Baseline characteristics, trends, and outcomes by insurance status over the ACA rollout period 2010-2018.

Extracorporeal membrane oxygenation in children: A brief review

With the advancement in technology and increasing familiarity, the use of extracorporeal membrane oxygenation (ECMO) has expanded in the past decade. Although ECMO can be lifesaving for critically ill children, it is an invasive therapy associated with complications that may necessitate rehabilitation and long-term follow-up. Paediatric clinicians play an essential role in managing these children, especially after the acute phase of their illness. This review provides an overview of ECMO and will provide a basic understanding of ECMO and its principles.

Mortality prediction in pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation: A comparison of scoring systems

Background

Pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO) patients have high mortality and morbidity. There are currently three scoring systems available to predict mortality: the Pediatric Extracorporeal Membrane Oxygenation Prediction (PEP) model, Precannulation Pediatric Survival After VA-ECMO (Pedi-SAVE) score, and Postcannulation Pedi-SAVE score. These methods provide risk stratification scores for pediatric patients requiring ECMO for cardiac support. However, comparative validation of these scoring systems remains scarce. We aim to assess the ability of these models to predict outcomes in a cohort of pediatric patients undergoing VA-ECMO after cardiac surgery, and identify predictors of in-hospital mortality.

Methods

A retrospective analysis of 101 children admitted to Fuwai Hospital who received VA-ECMO from January 1, 2010 to December 31, 2020 was performed. Patients were divided into two groups, survivors (n = 49) and non-survivors (n = 52) according to in-hospital mortality. PEP model and Pedi-SAVE scores were calculated. The primary outcomes were the risk factors of in-hospital mortality, and the ability of the PEP model, Precannulation Pedi-SAVE and Postcannulation Pedi-SAVE scores to predict in-hospital mortality.

Results

Postcannulation Pedi-SAVE score accessing the entire ECMO process had the greatest area under receiver operator curve (AUROC), 0.816 [95% confidence interval (CI): 0.733–0.899]. Pre-ECMO PEP model could predict in-hospital mortality [AUROC = 0.691 (95% CI: 0.565–0.817)], and Precannulation Pedi-SAVE score had the poorest prediction [AUROC = 0.582(95% CI: 0.471–0.694)]. Lactate value at ECMO implantation [OR = 1.199 (1.064–1.351), P = 0.003] and infectious complications [OR = 5.169 (1.652–16.172), P = 0.005] were independent risk factors for in-hospital mortality.

Conclusion

Pediatric cardiac ECMO scoring systems, including multiple risk factors before and during ECMO, were found to be useful in this cohort. Both the pre-ECMO PEP model and the Postcannulation Pedi-SAVE score were found to have high predictive value for in-hospital mortality in pediatric postcardiotomy VA-ECMO.

Race-based disparities in access to surgical palliation for hypoplastic left heart syndrome

BACKGROUND

Racial disparities in outcomes have been shown to persist in many operative specialties, including the management of congenital heart disease. Using a demographic-adjusted methodology, we examined whether patient race influenced access to high-performing centers for the operative management of hypoplastic left heart syndrome.

METHODS

The 2005-2017 National Inpatient Sample was queried to identify all pediatric (≤5 years) hospitalizations with an operation for hypoplastic left heart syndrome. A racial disparity index was generated for each hospital and defined as the proportion of White patients receiving operative management for hypoplastic left heart syndrome divided by the proportion of White patients admitted for respiratory failure. This methodology quantified hospital-level racial variation while adjusting for the local racial makeup of each center.

RESULTS

Of the 17,275 patients who met inclusion criteria, 64.1% were managed at high-volume centers. Patients at high-volume centers had a similar distribution of operative type, age, and burden of comorbidities. The mean racial disparity index steadily grew from 1.06 at the lowest volume decile of operative volume to 1.51 at the highest, indicating an increasing proportion of White patients as volume increased. Using risk-adjusted analysis, each decile increase in hospital volume was associated with a 14% relative reduction in odds of mortality and a 0.06 increase in predicted racial disparity index. Increasing volume was further associated with reduced odds of non-home discharge but did not alter resource utilization.

CONCLUSION

We demonstrate that high-volume centers disproportionally serve White patients and have superior clinical outcomes compared to low-volume centers. This study highlights the critical importance of equitable access to expert care for high-risk conditions such as hypoplastic left heart syndrome.

Arrhythmias Requiring ECMO in Infants Without Structural Congenital Heart Disease

Arrhythmias account for 55 per 100,000 patient evaluations in pediatric emergency departments. Most arrhythmias in children are amenable to medical management or cardioversion. Rarely, arrhythmias lead to significant hemodynamic instability requiring extracorporeal membrane oxygenation (ECMO) support. This study seeks to evaluate children under 1 year of age with a structurally normal heart requiring ECMO for an arrhythmia. This is a retrospective review of the Extracorporeal Life Support Organization Registry. All patients less than 1 year of age between 2009 and 2019 with a diagnosis of arrhythmia and without a diagnosis of structural heart malformation were included. Demographics, clinical characteristics, and outcomes were assessed with descriptive statistics and univariate and multivariable analyses. A total of 140 eligible patients were identified from the dataset. The most common arrhythmia was supraventricular tachycardia (SVT) in 70 (50%) patients. ECMO complications occurred in 106 (76.3%) patients and survival to discharge was achieved in 120 (85.7%) patients. In-hospital mortality was associated with neuromuscular blockade prior to ECMO [aOR 10.0 (95% CI 2.95-41.56), p < 0.001], neurologic ECMO complication [aOR 28.1 (95% CI 6.6-155.1), p < 0.001], and race with white race being protective [aOR 0.13, (95% CI 0.02-0.21), p = 0.002]. Similar survival and complication rates were found in subgroup analysis of SVT arrhythmias alone. Arrhythmias necessitating ECMO support in infants without structural congenital heart disease is a rare occurrence. However, survival to hospital discharge is favorable at greater than 85%. Given the favorable survival, earlier and more aggressive utilization of ECMO may result in improved outcomes.

Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda

Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.

Functional status of pediatric patients after extracorporeal membrane oxygenation: A five-year single-center study

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is a widely used treatment for circulatory and pulmonary support in newborns and young children. Over the past decade, the number of children successfully treated with ECMO has gradually increased. However, despite an increasing number of survivors, new morbidity and long-term health issues are becoming more prevalent. A better understanding of the pediatric ECMO prognosis contributes to improved treatment and care programs and minimizes the risk of sequelae and dysfunctions. We aimed to determine the incidence of new morbidity, prognoses, and follow-up data of survivors treated with ECMO in pediatric intensive care units (PICU) using the Functional Status Scale (FSS).

METHODS

We retrospectively collected and analyzed clinical data of patients in the PICU who received ECMO from January 2016 to January 2020. Clinical and functional outcomes were assessed at admission and discharge using the FSS. Twenty-seven patients aged between 1 month and 14 years who received ECMO in the PICU were included. Fifty-two percent were male, and the median age was 36 months (interquartile range, 21-114 months). The patients were admitted for fulminant myocarditis (n = 13), acute respiratory distress syndrome (ARDS) (n = 11), and septic shock (n = 3).

RESULTS

This study reviewed a single-center experience using the FSS for ECMO treatment in a PICU. The patients' original conditions included fulminant myocarditis, ARDS, and septic shock. Of the 27 patients who received ECMO, 9 (33%) died, 12 (67%) showed improved condition, and 6 (33%) discontinued treatment and left the hospital. Furthermore, the following adverse events were observed in the survivors who were discharged: nine (50%) cases of lower extremity deep vein thrombosis, seven (39%) jugular vein thrombosis, six (33%) acute kidney injury, five (27%) intracranial hemorrhage and cerebral infarction, and one each of (6% each) pulmonary embolism and peripheral nerve injury. Of the 12 patients who survived through 1 year after discharge, five (42%) recovered completely, whereas seven (58%) showed mild to moderate communication and motor dysfunction. The short-term survival rate and 1-year survival rate of ECMO patients were 67% (18/27) and 44% (12/27), respectively. Additionally, approximately one-third of the patients developed a new morbidity after ECMO treatment (6/18).

CONCLUSIONS

High mortality and new morbidity were common in patients who received ECMO treatment. New morbidity increased the risk of death and exacerbated the functional state. Follow-up and rehabilitation after discharge are essential to achieve positive outcomes.

Center Volume Impacts Readmissions and Mortality after Congenital Cardiac Surgery

OBJECTIVE

To characterize the relationship between surgical volume and postoperative outcomes in congenital heart surgery, we used a national cohort to assess the costs, readmissions, and complications in children undergoing cardiac operations.

STUDY DESIGN

The Nationwide Readmissions Database was used to identify pediatric patients (≤18 years) undergoing congenital cardiac surgery from 2010 to 2017. Hospitals were categorized based on deciles and tertiles of annual caseload with high-volume categorized as the highest tertile of volume. Multivariable regression models adjusting for patient and hospital characteristics were used to study the impact of volume on 30-day nonelective readmission, mortality, home discharge, and resource use.

RESULTS

Of an estimated 69 448 hospitalizations included for analysis, 56 672 (82%) occurred at high-volume centers. After adjustment for key clinical factors, each decile increase in volume was associated with a 25% relative decrease in the odds of mortality, a 14% decrease in the odds of nonhome discharge, and a 4% relative decrease in the likelihood of 30-day nonelective readmission. After risk adjustment, each incremental increase in volume decile was associated with a one-half-day decrease in the hospital length of stay, but did not alter costs of the index hospitalization. However, after including all readmissions within 30 days of the index discharge, high-volume centers were associated with significantly lower costs compared with low-volume hospitals.

CONCLUSIONS

Increased congenital cardiac surgery volume is associated with improved mortality, reduced duration of hospitalization, 30-day readmissions, and resource use. These findings demonstrate the inverse relationship between hospital volume and resource use and may have implications for the centralization of care for congenital cardiac surgery.

Palliative Care for Extracorporeal Life Support: Insights From the National Inpatient Sample

BACKGROUND

Providing temporary cardiopulmonary support, extracorporeal membrane oxygenation (ECMO) carries a high risk of mortality. Palliative care (PC) may facilitate a patient-centered approach to end-of-life care in order to aid symptom management and provide psychosocial support to families. The present study aimed to identify factors associated with PC consultation and its impact on resource utilization in ECMO.

STUDY DESIGN

All adults placed on ECMO at a PC capable center were identified in the 2006-2017 National Inpatient Sample. Indications for ECMO were identified using diagnosis codes and classified into postcardiotomy syndrome, respiratory failure, cardiogenic shock, mixed cardiopulmonary failure, and transplant related.

RESULTS

Of 41 122 patients undergoing ECMO, 20 514 (49.9%) died in the same hospitalization. Of those, 3951 (19.3%) received a PC consult. Use of PC consults increased significantly from 5.5% in 2006 to 22.8% in 2017 (nptrend<.001). After multivariable risk adjustment, PC consults did not affect costs (β: -$7341, 95% CI: -22 572 to +7888) or duration of hospitalizations (β: -.37 days, 95% CI: -2.76 to +2.02).

CONCLUSION

Utilization of PC does not appear to negatively influence resource utilization among non-survivors of ECMO. Increased adaptation of PC in ECMO may improve end-of-life care, a factor that deserves future study.

Association of Hospital Safety Net Status With Outcomes and Resource Use for Extracorporeal Membrane Oxygenation in the United States

PURPOSE

Safety net hospitals (SNH) have been associated with inferior surgical outcomes and increased resource use. Utilization and outcomes for extracorporeal membrane oxygenation (ECMO), a rescue modality for patients with respiratory or cardiac failure, may vary by safety net status. We hypothesized SNH to be associated with inferior outcomes and costs of ECMO in a national cohort.

MATERIALS AND METHODS

The 2008-2017 National Inpatient Sample was queried for ECMO hospitalizations and safety net hospitals were identified. Multivariable regression was used to perform risk-adjusted comparisons of mortality, complications and resource utilization at safety net and non-safety net hospitals.

RESULTS

Of 36,491 ECMO hospitalizations, 28.2% were at SNH. On adjusted comparison SNH was associated with increased odds of mortality (AOR: 1.23), tracheostomy use (AOR: 1.51), intracranial hemorrhage (AOR: 1.39), as well as infectious complications (AOR: 1.21, all P < .05), with NSNH as reference. SNH was also associated with increased hospitalization duration (β=+4.5 days) and hospitalization costs (β=+$32,880, all P < .01).

CONCLUSIONS

We have found SNH to be associated with inferior survival, increased complications, and higher costs compared to NSNH. These disparate outcomes warrant further studies examining systemic and hospital-level factors that may impact outcomes and resource use of ECMO at SNH.

Clinical and Financial Outcomes Associated With Vocal Fold Paralysis in Congenital Cardiac Surgery

OBJECTIVES

Vocal fold paralysis (VFP) has proven to increase resource use in several surgical fields. However, its burden in congenital cardiac surgery, a specialty known to be associated with high resource use, has not yet been examined. The authors aimed to assess the impact of VFP on costs, lengths of stay, and readmissions following congenital cardiac surgery.

DESIGN

A retrospective analysis of administrative data.

SETTING

The 2010-2017 National Readmissions Database.

PARTICIPANTS

All pediatric patients undergoing congenital cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Vocal fold paralysis was defined using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. The primary outcome of interest was 30-day nonelective readmissions and 90-day readmissions; costs, length of stay, and discharge status also were considered. Of an estimated 124,486 patients meeting study criteria, 2,868 (2.3%) were identified with VFP. Incidence of VFP increased during the study period (0.7% in 2010 to 3.2% in 2017, nptrend < 0.001). Rates of nonhome discharge (30.0% v 16.4%, p < 0.001), 30-day readmission (23.9% v 12.4%, p < 0.001), and 90-day readmission (8.3% v 4.4%, p = 0.03) were increased in the VFP cohort, as were lengths of stay (42.1 v 27.0 days, p < 0.001) and costs ($196,000 v $128,000, p < 0.001). After adjustment for patient and hospital factors, VFP was independently associated with greater odds of nonhome discharge (adjusted odds ratios [AOR], 1.66, 95% CI, 1.14-2.40), 30-day readmission (AOR, 1.58, 95% CI, 1.03-2.42), 90-day readmission (AOR, 2.07, 95% CI, 1.22-3.52), longer lengths of stay (+ 6.1 days, 95% CI, 1.3-10.8), and higher hospitalization costs (+$22,000, 95% CI, 3,000-39,000).

CONCLUSIONS

Readmission rates after congenital cardiac surgery are significantly greater among those with VFP, as are costs, lengths of stay, and nonhome discharges. Therefore, further efforts are necessary to increase awareness and reduce the incidence of VFP in this vulnerable population to minimize the financial burden of congenital cardiac surgery on the US medical system.